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CONTENTS 1) Neuro 2

- sensory - pupils- motor

2) Peds 11- non-strabismus- strabismus

3) Plastics 24

© Mark Cohen 1998 – modified by Mounir Bashour 1999

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1) NEUROA) SensoryDDX of assymptomatic disc swelling- normal retina; normal vision- noted by MD1) ICP2) IOP or acute IOP 3) intraorbital pressure (orbital tumors)4) systemic CO25) hyperopia6) o.n. drusen7) disc hamartoma (eg. astrocytoma)

Ddx of symptomatic disc edemaA) Vascular1) AION2) CRVO3) malignant hypertension4) benign papillophlebitis (minimal symptoms)5) diabetic papillopathy (minimal symptoms)

B) Inflammation1) papillitis (optic neuritis)2) uveitis3) Leber’s idiopathic stellate neuroretinitis

C) Raised orbital pressure1) TRO2) orbital tumor

D) Raised ICP1) tumor2) IIH

E) O.N. tumors1) glioma2) meningioma

F) Infiltration 1) leukemia2) lymphoma3) myeloma4) granuloma (sarcoid, TB)

G) Infectious1) toxocara of disc2) TB3) toxoplasma4) CMV

5) Lyme disease

H) Other1) trauma

Optic disc drusen associations1) angioid streaks2) RP3) chronic papillitis/optic atrophy4) chronic glaucoma (COAG)5) vascular occlusions (drusen occlude)6) with phacomatoses (giant drusen)7) idiopathic (most common) - some AD

DDx of swollen disc with otherwise normal eye exam- swollen nerve and rest normal; decreased vision1) optic neuritis (M.S.)2) diabetic papillopathy3) LISN (Leber’s idiopathic stellate neuroretinitis) 4) AION5) benign papillophlebitis (normal recovery)* see above optic neuritis

DDx unilateral optic atrophyA) Neoplastic1) glioma2) meningioma3) craniopharyngeoma4) pit adenoma (post fixed)?5) treated leukemia of ONB) Inflammatory1) optic neuritis2) traumaC) Vascular1) AION2) old CRAO3) old CRVOD) Infectious1) syphilisE) Pressure1) ACG episode2) COAG3) old papilledemaF) Other1) Leber’s optic atrophy

ON collaterals (optociliary shunt)


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- more correctly “acquired cilioretinal veins” or “optociliary anastomoses” (vein to vein)- “optociliary shunts” is a misnomer (not artery to vein)A) Head Squishing1) CRVO/BRVO ** common (vein to vein)2) COAG3) chronic papilledema 4) ON drusen B) Nerve Squishing1) ON meningioma (espec. optic canal)2) ON glioma (rare)3) any orbital or intracranial tumor (theoretically)4) ON arachnoid cyst5) craniosynostosis (optic canal narrowed)6) ON sarcoidosis (granuloma)

Ddx of nonarteritic AION (normal ESR) or optic neuritisA) Vascular1) idiopathic (small cup:disc)2) temporal arteritis (normal ESR)3) sickle cell anemiaB) Inflammation1) optic neuritis2) SLE1) sarcoidC) Infectious1) HZV2) HSV3) CMV4) Syphilis

Ddx PIONA) Vascular1) temporal arteritis2) post CABGB) Inflammation1) syphilis2) retrobulbar neuritisC) Other1) radiation

DDx of optic neuropathy- bilateral central or centrocecal scotomas A) Inflammatory1) optic neuritis - see aboveB) Vascular1) AION

C) Toxic i) Meds- 4 are TB meds1) Isoniazid 2) Rifampin3) Ethambutol4) Streptomycin5) Chloramphenicol6) Quinineii) Nutritional1) tobacco-alcohol2) thiamine (B1?) deficiency 3) B12 deficiency4) folate deficiencyiii) Toxins1) methanol2) lead

D) Hereditary1) A.D. (Kjer)2) A.R. (Behr’s)3) x-linked4) mitochondral (Leber’s)5) syndromic (assoc. with DM, DI, ataxia)

E) Infectious 1) TB2) syphilis

F) Pressure1) papilledema

ON thickening on CTA) Kids1) glioma - kids2) RB (kids)3) leukemiaB) Adults1) meningioma (train track) - adults2) mets3) OID4) sarcoid5) papilledema 6) ARN

VF defectsA) Altudinal1) AION2) optic neuritis


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3) hemiretinal vein occlusion4) hemiretinal artery occlusion5) RD6) bilateral occipital infarcts

B) Arcuate (NFB)i) Retina1) vascular occlusion2) juxtapapillary retinochoroiditis 3) RD4) Retinoschisis5) myopia with perip. atrophy6) atypical RP ii) ON head1) glaucoma 2) ON drusen3) ON head pits4) colobomas5) AION6) chronic papilledema7) optic neuritis8) hypotensive episodeiii) Optic nerve lesion (rare)1) meningioma2) chiasmal lesions: pituitary adenomaiv) Other1) prominent nose

C) Binasali) Retina1) atypical RP2) schisis3) vascular occlusion (2 vessels)4) juxtapapillary retinochoroiditis 5) myopia with perip. atrophyii) ON Head1) glaucoma2) disc drusen3) chronic papilledemaiii) Chiasm1) tumor2) aneurysm (compressing both o.n. or the chiasm)

D) Bitemporal I) chiasmal lesion1) pit. adenoma2) meningioma3) craniopharyngioma

4) aneurysm5) gliomaII) other1) tilted discs2) nasal RP3) dermatochalasis4) refractive error

E) Cecocentral1) tobacco/alcohol2) nutritional amblyopia3) toxic (see earlier)4) optic nerve pit5) any lesion that causes central scotoma

DDx of constricted VFA) Nerve problems1) disc drusen2) chronic papilledema3) glaucoma4) peripheral optic neuritis (syphilis)

B) Retina problems1) retinoschisis2) RD3) RP4) choroidemia5) PRP6) CRAO with cilioretinal artery sparing

C) Medications (retina)1) quinine2) thioridazine3) salicylates 4) carbon monoxide poisoning

D) Optical1) aphakic with ring scotoma2) cortical cataract3) rim artifact4) wrong perscription5) on miotic

E) Other1) malingerer2) bilateral occipital infarcts with macular sparing

DDx of Large ON1) coloboma


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2) ON pit3) morning glory syndrome4) megalopapilla5) ON edema6) ON drusen7) Aicardi’s syndrome - x-linked

LGNipsilateral: 2,3,5contralateral: 1,4,6

Findings in optic nerve drusen1) caucasians only2) peripapapillary hemorrhage3) SRNV4) pseudopapilledema5) autofluorescence6) bilateral in 80%

Ddx of transient visual obscurations (less than 24 hours; usually < 1 hour)Seconds:1) papiledema (usually bilat.)2) ON drusen3) GCA4) glaucoma

<10 Minutes:1) amaurosis fugax (unil.)2) vertebrobasilar insufficiency (bilat.)3) orthostatic hypotension4) ocular ischemic syndrome

10-60 minutes:1) migraine

Other:1) impending CRVO2) o.n. tumor 3) optic neuritis (Uthoff’s)4) AION5) CNS lesion

Classified AnatomicallyA) Nerve1) papilledema (usually bilat.)2) ON drusen3) GCA4) glaucoma

5) optic neuritis (Uthoff’s)6) AION7) optic nerve tumor B) Retina1) amaurosis fugax (unil.)4) ocular ischemic syndrome3) impending CRVOC) CNS1) migraine2) vertebrobasilar insufficiency (bilat.)3) orthostatic hypotension4) CNS lesion

Non-ocular causes of photophobia- all irrtate CNS, nerves or meninges1) migraine2) meningitis3) retrobulbar optic neuritis4) subarachnoid hemorrhage5) trigeminal neuralgia

Decreased vision with normal fundus in adultsA) Nerve1) retrobulbar optic neuritis2) optic neuropathyB) Retina1) cone dystrophy2) rod monochromatism 3) Stargardt’sC) Other1) non-physiologic loss

ON hypoplasiaA) Maternal causes1) alcohol2) LSD3) quinine4) phenytoin5) DM in pregnancyB) Fetal causes1) aniridia2) idiopathic3) deMorsier’s4) congenital CMV5) hydrocephalus6) brain structure anomalies (anencephaly)

Pseudotumor (IIH) Associations


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1) obesity2) COPD3) otitis media4) nonspecific infections (post-viral)5) pregnancy?6) radical neck dissectionA) Associated with Medications1) Vit A (isoretinoin?)2) tetracycline3) nalidixic acid4) corticosteroids 5) lithium (Duanes’)6) amiodarone (new) (Duanes’)7) danazol (androgen) (new) (Duanes’)

Causes of ON demyelination - have increased VER latency1) Vit B12 defic.2) Parkinson’s3) MS

Signs of optic disc edemaA) Mechanical signs1) elevation of ON head2) blurring of disc margins3) filling in of physiologic cup4) peripapillary NFL edema5) retinal choroidal folds

B) Vascular signs1) hyperemia2) venous dilation3) peripapillary hemorrhages4) hard exudates5) cotton wool spots


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B) PupilsDDx of internal ophthalmoplegiaA) Orbital1) orbital apex syndrome (any cause)2) mucormycosis3) post-trauma4) post retrobulbar5) post-BotoxB) Ocular1) post-PRP

DDx of light - near dissociation1) syphilis2) Adie’s3) Parinaud’s syndrome4) myotonic dystrophy5) diabetics6) aberrant third nerve regeneration7) primary systemic amyloidosis

Argyll Roberston pupil associations- lesion: aqueduct of Sylvius1) syphilis 2) DM pupil neuropathy3) alcoholism4) MS 5) encephalitis6) degenerative disorders (CNS)7) sarcoid ?

Signs of Argyll Robertson pupil 1. Visual function grossly intact2. Decreased pupillary light reaction3. Intact near response4. Miosis5. Pupils irregular6. Bilateral, asymmetric7. Poor dilation8. Iris atrophy variable

DDx of Tonic pupils (DDx of Adie’s)A) Inflammatory1) idiopathic (Adie’s)2) Guillaine BarreB) Infectious1) HZV2) syphilis3) orbital infectionC) Vascular

1) temporal arteritis2) diabetesD) Other1) orbital trauma2) alcohol

Bilateral Tonic Pupils1) DM2) alcohol3) cancer associated dysautonomia4) amyloidosis associated dysautonomia5) Riley Day syndrome (familial dysautonomia)

Adie’s characteristics1) light near dissociation2) poor tendon reflexes3) poor response to Atropine

Causes of Parinaud’s1) pinealoma2) ischemia3) metastatic tumor4) MS5) hydrocephalus

Paradoxical Pupils (dilate in light)- normal light is too much for these eyes to handleA) Common causes1) CSNB (most common)2) achromatopsia3) O.N. hypoplasiaB) Rare causesi) Retina1) Leber’s congenital amaurosis (kid RP)2) RP3) albinism4) cone dystrophy 5) Best’s diseaseii) Optic nerve1) amblyopia2) optic neuritis3) dominant optic atrophy

AnisocoriaA) eye miotic1) on miotic in 1 eye2) physiologic anisocoria3) Horner’s


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4) syphilis (Argyll Robertson)5) iritis6) longstanding Adie’s7) episodic spasm of the iris sphincterB) eye dilated1) pharmacologic (adrenergics, mydriatics)2) 3rd nerve palsy3) Adie’s4) damage to ciliary ganglion 5) physiologic6) iris spincter damaged (trauma)7) episodic unilateral mydriasis

Aneurysms1) posterior comm. artery: most common with eye signs (15% of all aneurysms)2) anterior comm. artery: 50% of all aneurysms

Drugs which cause mydriasis1) LSD2) amphetamines3) cocaine4) marijuana5) mescaline6) carbamazepine

Drugs which cause miosis1) narcotics (pinpoint)

Pupil size1) Relaxed (sleep, coma): miosis2) excited (seizure): dilates

Pupil Reflexes1) lateral gaze: abducting eye dilates 2) forced lid closure: constricts3) ciliospinal reflex: pain dilate4) loud sound: dilate

Lesions in Horner’sA) First order (between pons? And sympathetic chain (C7-T2)- numbness, ataxia, nystagmus, weakness1) vascular occlusion (lat medullary syndrome)2) vertebrobasilar insufficiency3) tumors4) cervical disc disease

B) Second order (between sympathetic chain in upper thorax and the superior cervical ganglion in the upper neck - through stellate ganglion)- trauma, cough, hemoptysis, neck swelling1) apical lung tumors2) thyroid tumors3) chest surgery4) thoracic aortic aneurysms5) trauma to brachial plexus (eg birth trauma)6) sympathetic chain tumors (neuroblastoma in kids)

C) Third order- signs: anesthesia over V1, V2 +/- V31) upper neck tumors2) carotid artery surgery 3) compressive tumors on carotid4) spontaneous dissection of carotid5) cavernous sinus tumor invasion by nasopharyngeal carcinoma6) cluster headaches7) Raeder’s paratrigeminal syndrome 8) migraines9) Tolosa Hunt10) congenital Horner’s ? (upper neck trauma?)


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C) MotorDdx of External OphthamoplegiaA) Central1) CPEO2) progressive supranuclear palsy (S-R)3) migraine4) myotonic dystrophy5) Huntingdon’s disease6) Wilson’s disease7) olivopontocerebellar atrophy8) PPRF lesions9) Parkinsons’s disease (late)10) Alzheimer’s disease (late)11) ataxia-telangiectasia12) Whipple’s diseaseB) Subarachnoid space1) Guillaine Barre (Miller Fisher variant)2) carcinomatous meningitis3) meningiomaB) Cavernous Sinus/ SOF1) cavernous vein thrombosis2) cavernous sinus tumor (carcinoma)3) mucormycosis4) pituitary apoplexy or adenoma5) OID of cavernous sinus (Tolosa Hunt)6) A-V fistula7) TB, sarcoid8) metastases9) lymphomaC) Orbit/EOM’s1) orbital pseudotumor2) orbital cellulitis3) mucormycosis4) orbital tumors (primary and mets)5) myasthenia

Classification of Nystagmus1) Congenitala) sensoryb) motor2) Acquired (most types)3) Induced (eg MS)4) With related conditions- jerk nystagmus: problem is slow phase; fast phase is correcting movement

Congenital Nystagmus1) congenital motor- have null point

- no oscillopsia- dampens with convergence- improves with age- remains horizontal in downgaze and upgazetreatment:a) Kestenbaum procedureb) contact lenses

2) manifest latent- towards uncovered eye- seen with strabismus

Acquired Nystagmus (cranial caudal)VSCAVRUPDVery Suddenly, Canadians Are Very Rigid; Grumpy Until the Province (quebec) Departs 1) voluntary: cerebral origin- rapid- unsustained- induced by convergence

2) see-saw: chiasmal lesions (diencephalon/thalamus)- pendular, torsional

3) convergence retraction: dorsal midbrain (mesencephalon)- signs of Parinaud’s

4) ataxic or “dissociated” (mesencephalon/pons) (MLF)- INO (in Abducting eye)

5) vestibular (pons)- jerk type, +/- rotatory- central and peripheral types

6) gaze evoked (posterior fossa)- in field of gaze- not present in primary gazecauses: CPA tumor, drugs

7) rebound (cerebellum)- seen on return to primary gaze

8) upbeat (medulla, cerebellum)- deficit in upward pursuit- present in primary gazecauses: tumors, drugs (phenytoin)


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9) periodic alternating (medulla or craniocervical jxn)- occurs during sleep- lesions: demyelinating, vascular

10) downbeat (cervico-medullary jxn)- deficit in downward pursuit- present in primary position- worse in horizontal and downgaze- better in upgaze- causes: - Arnold-Chiari malformation, MS, alcohol abuse, spinocerebellar degeneration, B12 defic., anticonvulsants, lithium

Nystagmus which remains horizontal in upgaze and downgaze1) congenital motor2) vestibular3) periodic alternating nystagmus

Causes of Uniocular Nystagmus1) MS (INO) - abducting eye2) spasmus nutans - some3) chiasmal gliomas4) SO myokymia

Nystagmus Blocking Syndrome1) horizontal nystagmus2) variable eso3) nystagmus greater whan abducting eye fixes4) nystagmus less when adducting eye fixes5) head turn towards fixing eye6) maybe associated with CNS pathology7) Tx. Recession of MR with post. fixation suture

Congenital Motor Nystagmus1) uniplanar, pendular, conjugated2) decrease with convergence4) increases with fixation (eg. chart)5) latent nystagmus assoc6) inverted OKN7) no oscillopsia8) stops during sleep9) binocular10) head oscillation11) null point (some cases) 12) head towards fast phase - Polomeno(doesn’t make sense)

Latent Nystagmus1) beats towards uncovered eye2) diminished visual acuity3) assoc. with infantile ET

Cerebellar disease signs1) opsoclonus2) square wave jerks3) ocular dysmetria (saccades)4) ocular flutter5) rebound nystagmus6) upbeat nystagmus7) past pointing8) jerky pursuit9) skew deviation10) saccadic intrusions?11) can’t overide VOR?

DDx of Opsoclonus1) cerebellar disease2) neuroblastoma3) breast cancer

DDx of facial twitching- basal ganglia is the center for involuntary eyelid closure (affected in Parkinson’s, antipsycotics)- do CT or MRI for all (for exams)A) Local1) essential blepharospasm - basal ganglia; bil. 2) hemifacial spasm - CN 7 in CPA; unilateral 3) facial myokymia; unilateral; CN 7 nucleus 4) facial tic (habit spasm)5) lid myokymia6) tic douloureux - in response to CN 5 pain4) focal cortical seizures (cortical facial region)B) Systemic Diseases1) Parkinson’s (b.g.)2) tardive dyskinesia (b.g.)3) Huntingdon’s chorea (b.g.)4) Tourette’s syndrome5) meningeal irritationC) Other1) corneal irritation (reflex blepharospasm)2) hypocalcemia

Initial upgaze palsy1) Parinaud’s


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Initial downgaze palsy1) Parkinson’s2) CVA3) Steele Richardson (PSNP)

Causes of fourth nerve palsy1) congenital (see pediatric causes)2) trauma3) hydrocephalus4) vascular (CVA)5) vascular loops6) tumor (glioma)7) carcinomatous meningitis

Causes of sixth nerve palsyA) General1) hydrocephalus2) vascular (HTN, DM, GCA)3) demyelinating4) alcohol encephalopathy (Wernicke-Korsakoff)6) trauma7) mastoid infections (Gradenigo’s)B) Tumorsi) gliomas (central)ii) meningiomas (SA space)iii) chordoma (clivus)iv) accoustic neuroma (CPA)v) nasopharyngeal carcinoma (cavernous sinus)C) Syndromes1) Duane’s2) Moebius Pediatric nerve paresis causes1) trauma2) tumors3) migraine4) meningitis (during and after)5) post infectious (eg. viral)6) post vaccination

Pediatric brain tumors1) glioma (ON, brain stem, chiasm)2) astrocytoma3) ependymoma4) medullobalstoma


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D) TreatmentsCN 3 palsy due to aneurysm1) pupil involved in 95%2) pain always present3) younger patients

CN 3 palsy due to ischemia1) older patients2) intense pain often present3) resolve in 12 weeks4) pupil involved in 5%

Treatment of CN 3 palsyA) seems nuclear or fascicular on physical1) MRI or at least high-resolution CT

B) if accompanying meningeal signs or other cranial nerve involvement even if pupil spared1) LP2) CT with and without contrast3) cerebral angio

C) if localized to cavernous sinus on exam1) MRI with contrast

D) all patients 10 - 50 years old (without vascular risk factors?) 1) complete neurologic evaluation2) cerebral angiogram

E) patients > 50 with isolated, pupil-sparing, complete third-nerve palsy1) ESR2) CBC3) glucose tolerance test4) BP5) observe Qday x 5 days for evidence of pupillary involvement then Q 6 weeks

F) patient > 50 with isolated complete oculomotor nerve palsy with pupillary involvement1) CBC, ESR, glucose tolerance2) MRI3) cerebral angiography

G) patient > 50 years old with a incomplete third-nerve palsy, pupil spared 1) CBC, ESR, glucose tolerance2) MRI

3) cerebral angiography (probably)

H) any patient with incomplete third nerve palsy and pupil involved1) MRI2) angio

I) kids < 10 years old1) probably migraine2) angio controversial (aneurysms rare)

Treatment of CN 6 palsy1) CBC2) ESR3) FU Q 6 weeks

Indications for ONSF in IIH (Jakobiec)1) development of a new visual field defect2) enlargement of a previously existing field defect3) presence of severe visual loss in one or both eyes at the time of first examination

Treatment of SO myokimia1) tegretol (carbamazepine)2) inderal (propanolol)

Treatment of hemifacial spasm1) Tegretol2) Baclofen3) Janetta procedure4) Botox

Treatment of facial myokymia1) Tegretol (carbamazepine)2) Dilantin (phenytoin)

Treatment of benign essential blepharospasm1) haloperidol2) clonazepam3) Botox4) selective facial nerve sectioning5) extirpation of lid protractors (not done)

Treatment of IIH1) CT/MRI2) diagnostic LP (> 250 mm H2O)3) D/C problem meds4) lose weight, decrease sodium intake


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5) Diamox6) Lasix: 80 mg/ day7) repeat LP8) optic nerve fenestration 9) migraine treatment for HA before VPS10) VP shunt

Treatment of optic neuritis- MRI if available- If 2 lesions (periventr. abnorm. > 3 mm) or more (67% have less than 2):1) IV prednisolone: 250 mg IV Q 6h x 3 days2) po steroids: 60-80 mg po Qday x 11 days- may delay onset of MS, but does not affect chance of developing MS - no change in vision long term (faster recovery)

Myasthenia Tests (Neil Miller)1) Tensilon (edrophonium) IV; 2mg then observe for 60 seconds; then 8 mg2) Prostigmin test (neostigmine) IM in kids; works in 45 minutes3) sleep test - sleep 1 hour4) ice test - ice to lids5) EMG6) relax in hallway ith eyes closed 10-15 minutes

Physical Exam1) lid lag2) look up at finger for 1 minute; see if ptosis worsens or diplopia develops3) pupils should be normal4) swallowing

Workup of Myasthenia1) MRI - head2) serum anti ACh antibodies3) EMG4) CT chest for thymoma (all)5) TFT’s

Treatment of myasthenia (Neil Miller)1) nothing2) anti-cholinesterase meds (Mestinon, Prostigmine)3) thymectomy4) steroids5) immunosupression6) plasmapharesis

7) surgery (lids, muscles) - rare

Treatment of traumatic optic neuropathy (Jakobiec)I) Anterior type- edematous nerve head - dilated retinal veins II) Posterior type- normal nerve head- medical treatment should be instituted as soon as the diagnosis is made; it should not be withheld while awaiting neuroimaging studiesDirect injury: bone or f.b. impinging nerveIndirect: no bone or f.b. seenTraumatic:- vision can be from 20/40 (Spoor) to NLP for treatment A) Initial treatment1) methylprednisolone: 2g loading dose, followed by 1g every 6 hr for 3 to 5 days(most common side effect of high-dose corticosteroid treatment is cardiac arrhythmia)2) taper with oral steroids for 7-10 days (follow daily)B) Later treatment- if delayed loss of vision develops while on high-dose corticosteroids or during tapering of corticosteroids then a compressive lesion is assumed- do imaging:1) lateral canthotomy or orbital drainage (if have orbital soft tissue swelling or subperiosteal hematoma comprimising nerve) 2) optic nerve sheath fenestration (for an intrasheath optic nerve hematoma) 3) decompression of the optic canal (if neuroimaging shows the presence of bone fragments or foreign bodies impinging on the optic nerve; if no such lesions are seen, surgical intervention is controversial)

Treatment of Meningioma- will grow slowly (vs. glioma which may not grow) 1) CT2) if ON tumor grows towards chiasm, consider surgical resection3) mifepristone (RU 486) - experimental

Meds for Migraines


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A) During Attack1) sumatriptan ? (serotonin)2) ergotamine compounds3) caffeine compounds4) NSAIDsB) Prophylactic2) beta blockers3) calcium channel blockers4) amitryptiline (anti-depressant)5) NSAIDsC) Avoid1) alcohol2) cheese3) chocolate4) BCP

Types of Headaches with no signs on exam1) migraine- common- classic- complicated2) tension3) cluster (type of migraine)4) Raeder’s trigeminal5) trigeminal neuralgia6) glossopharyngeal neuralgia7) carotodynia8) TMJ syndrome9) HZV -pre or post breakout


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2) PEDIATRICSA) Non-strabismusDDx of ophthalmia neonatorumA) normal vaginal flora1) Candida 2) staph3) coliforms 4) strep5) acinobacter6) strep pneumo7) H.flu

B) abnormal vaginal flora1) gono2) chlamydia3) HSV

C) Other1) chemical (silver nitrate) time:chemical < 24 hours;gono 1-3herpes 1-5 dayschlamydia: 5-14 days

Corneal leukoma in infantsA) Descemet’s/endothelium1) congenital glaucoma2) forceps injury3) Peter's4) posterior ulcer (Von-Hippel)5) posterior keratoconus6) CHED B) Stromal1) sclerocornea2) MPS/ML3) CHSD4) limbal dermoids5) cystinosis?6) NF?C) Infectious1) ToRCHS (HSV, rubella, syphilis)2) neonatal ulcer (gono)

Ddx of Leukocoria (white pupil)1) PHPV (small eye)2) RB (6-18 months)3) toxocara (young child)

4) Coat’s (child)5) ROP6) coloboma 7) cataract8) RD9) retinal dysplasia10) uveitis11) myelinated nerve fibers12) other tumors13) vitreous hemorrhage14) morning glory disk15) Norrie’s disease16) FEVR17) combined hamartoma

Lesions which mimic RB on retina exam1) astrocytic hamartoma 2) retinocytoma3) toxocara (young child)4) Coat’s (child)5) combined hamartoma6) PHPV7) RD8) retinal dysplasia9) active toxoplasmosis10) medullepithelioma

Ddx of pediatric glaucoma1) congenital glaucoma2) ectropion uvea3) Sturge Weber4) rubella (serology)5) neurofibromatosis (rarely)6) Lowe’s syndrome (urine aa)7) Axenfeld/ Rieger’s/ Peter’s8) trauma9) syphilis10) aniridia11) PHPV

Cataract + glaucoma1) rubella2) Lowe’s3) PHPV

Periorbital ecchimosis 1) trauma2) neuroblastoma3) leukemia


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corneal diameter in infants: 10 mminvestigate diameters < 9 and > 11

Forms of CSNB1) AD, AR, and X-linked with normal fundus2) Oguchi’s disease3) fundus albipunctatus

Associations with foveal hypoplasia1) albinism2) aniridia3) amaurosis (Leber’s)4) achromatopsia5) CSNB6) PHPV7) ON hypoplasia?

VH in children1) trauma2) retinoschisis3) PHPV4) ROP5) Coat’s6) pars planitis7) coag. disorder8) RB9) Eales’

Hyphemas in kidsA) Neoplastic1) JXG2) RB3) medulloepitheliomaB) pupilary or retrolental vasculary mb:1) PHPV2) ROP3) Coat’sC) Other1) HSV2) HZV3) trauma4) severe iritis5) coag. Disorder

Sx for hyphema—corneal blood staining—total hyphema—IOP > 50 for > 5 days

—total hyphema > 50% after 6 days with IOP > 25—day 4 best for AC washout

—express clot with Healon—I/A ± vitrector—± trabeculectomy

Stages of ROPno ROP: no demarcation line1: demarcation line2: ridge3: ridge with NV4: subtotal RD5: total RD

Zones in ROPZone 1: 30 degree radius circle around disc (2x disc-macula distance)Zone II: Zone I to nasal ora

ROP cryo studyIndications for treatment: 1) Stage 3 (ridge with NV)2) plus disease3) 5 contiguous or 8 total clock hours4) zone 1 or 2Treatment reduces unfavorable outcome risks(RD, fixed macular folds)

who to screen for ROP:1) BW < 1500 g (AAO says 2000 and got oxygen)2) GA < 36 weeks (AAO) (normal GA is 40 weeks) - Bloom says 30 weeks3) first exam 4-6 weeks post-gestation (after birth) or at 30 weeks total (later of the two)

Risk of Threshold ROP1) < 750g: 15%2) 750-1000: 7%3) 1000-1250: 2%

To Dilate:1) cyclopentalate 0.2% (max 0.5%)2) phenylephrine 1%

Follow up for ROP:1) no ROP : Q4 weeks until retina vascularizedor Stage 1?


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2) stage 2 ROP: Q2 weeks until retina vascularized3) stage 2 + or stage 3 prethreshold: Q 1 week (earlier if have “plus”, known as “rush” disease)4) Threshold: cryo within 72 hours85% have spontaneous regression

- All eyes have a complete eye exam at 3 months corrected age (when macula is developed)

Laser for ROP1) easier to treat posteriorly2) less trauma to eye3) easier for patient4) done in ICU vs OR?5) less myopia?

Note: 1) gestational age: since LMP (40 weeks or 280 days)2) fertilization age: since ovulation (38 weeks or 266 days total)

Sequelae of ROP1) RD 2) myopia3) cataract4) macular dragging5) glaucoma

Poor vision and normal fundus in infant- do ERG to confirm1) Leber’s (10% of cases)2) achromatopsia (rod monochromatism)3) blue cone monochromatism4) CSNB5) cortical visual impairment (“blindness”)6) delayed visual maturation

Nystagmus in infantA) Motor1) congenital motor nystagmus2) NBS3) spasmus nutans4) thalamic injuryB) Sensory1) congenital cataract2) albinism3) Leber’s congenital amaurosis

4) aniridia5) achromatopsia6) TORCHS7) glioma (O.N. or chiasm)8) o.n. hypoplasia9) congenital glaucoma10) cornea leukoma

Microphthalmos associations1) PHPV2) isolated (nanophthalmos)3) rubella4) microphthalmos with cyst5) trisomy 13

Disorders with defective DNA processing1) xeroderma pigmentosum2) Bloom’s syndrome3) Fanconi’s anemia4) Cockayne syndrome5) ataxia telangiectasia

Congenital cataractsA) Bilateral1) sporadic (60%)2) heriditary without syst. Assoc. (30%)3) with syst. disease: 5%4) with TORCHS: 3%5) with other ocular abnormalities: 2%

B) Unilateral1) sporadic: 80%2) ocular abnormalities: 10% (PHPV)3) traumatic: 10% (beware child abuse)

Chloral Hydrate in kids:1) oral or suppository2) sedation only3) very slight resp. supression4) good for children < 3 y.o.5) monitor VS6) dose: 50-100 mg/kg; repeat at half initial; dose if necessary7) give on empty stomach

DPT (Demerol, Phenergan, Thorazine)1) better for older children2) sedation and anesthetia3) good for painful procedures


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4) used only when a pediatrician immediately available

Workup for Aniridia1) family Hx, examine family2) IOP + gonio (EUA if necessary) 3) BP (elevated in Wilm’s)4) Genetics and Peds referal5) karyotyping (see if chrom. 11 deletion)5) regular urinalysis and abdo. U/S Q3 months until age 5 (Wills says Q 6 months if karyotyping is normal)6) IVP if U/S abnormal 7) regular pediatrician exam

B) Strabismus and visual developmentDevelopment Stages in KidsWright 1) birth: - pupil response- vestibular generated eye movements (VOR)- OKN: present but slow and poor- fixation present (1 study)- conjugate horizontal gaze2) 1 month- stable alignment3) 2 months- fixation reflex(most studies): CSM refers to fixation- saccades- conjugate vertical gaze- following (pursuit)- OKN- dampening of VORAAO 1) birth: blink reflex to light2) 6 weeks: fixation and maintenance with “happy” response in expression3) 2-3 months: interest in bright objects4) first 4 months: disconjugate eye mvts

Signs of Poor visual dev’t to parents1) nystagmus (3 months)2) wandering eye mvts3) lack of response to familiar faces4) staring at bright lights

5) oculodigital massge

Signs of Poor visual dev’t to MD1) poor light response2) poor visual attention3) inability to fix object

Tests of visual acuity in preverbal children (less than 2 years)1) OKN- 20/400 at birth- 20/100 at 6 months- 20/20 at 2 years2) pattern VEP- 20/400 at birth- 20/20 at 6 months3) preferential looking (Teller cards) - 20/400 at birth - 20/200 at 6 months- 20/20 at 2 years

** difference may be from association visual areas developing more slowly - first test monocular status then binocular status (binocular more sensitive to detect amblyopia)4) dampening of VOR: after spinning in chair, nystagmus should stop in 30 seconds due to fixation reflex - young infants

Tests of acuity in verbal children1) Allen cards (photos) - 3 years2) Tumbling E - 5 years3) Landolt C - 5 years4) school age (5-6): Snellen letters

Stereopsis Tests1) Titmus stereo acuity (polarized)2) Randot stereograms3) 2 pencil test

Diplopia tests (from most to least dissociating)- 1 target1) Maddox rod (most)2) dark red filter3) Worth 4 dot (lights out)4) Worth 4 dot (lights on)5) Bagolini lenses


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Tests for supression + NRC vs ARC1) Worth 4 dot2) Bagolini striated lenses3) vertical prism plus red filter over 1 eye (“does patient see 2 images?”)4) afterimage test: note: here crossed afterimage is seen in ET with ARC (opposite of the usual)5) amblyoscope

Tests to detect ocular alignment A) Cover tests1) cover/ uncover: detects tropia2) alternate cover: total phoria + tropia3) simultaneous cover: detects phoriaB) light reflex tests1) Hirshberg2) Krimsky3) Bruckner4) major amblyoscope (look at reflex)C) Dissimilar image tests (diplopia)- 1 target1) Maddox rod 2) double (1R 1W) Maddox rod: torsions3) red filter test4) Bagolini lensesD) Dissimilar target tests (haploscopic)- 2 targets1) Lancaster red-green test2) Hess screen3) Lees screen4) amblyoscope

W4D: far: 1.25 degreesnear (33 cm): 6 degrees

Test to detect amblyopia1) 15 PD vertical prism: - to detect amblyopia in straight eyes- prism over 1 eye; - breaks up central scotoma & periph. fusion complex- Ques: does pt still maintain in CSM testing?

History of poor seeing child1) pregnancy (meds, rads, cx., infections)2) delivery (cx., trauma)3) perinatal problems (oxygen, bradycardia, etc)

3) family history of vision problems4) developmental stages of child

Krimsky reflex1) pupil margin: 15 degrees (30PD)2) between pupil and limbus: 30 degrees (60 PD)3) at limbus: 40 degrees (80PD)

Causes of Chin Up (difficulty looking up)1) Brown’s2) V pattern XT3) A pattern ET4) double elvator palsy5) ptosis6) torticollis7) myasthenia8) congenital nystagmus (null point in down gaze)

Anomalous head position:A) Ocular 1) strabismus- Duane’s- Brown’s- A and V patterns- Ciancia2) cong. nyst. with head position3) orbital neoplasm4) myasthenia5) ptosisB) Systemic1) sternomastoid hypoplasia2) cervical spine anomalies3) decreased hearing

Types of Ambyopia1) Strabismic (ET, XT, rarely X(T))2) Monocular pattern a) ametropic:

- anisometropia- unil. astigmatism

b) media opacity- cataract- corneal opacity- vitreous hemorrhage

3) Binocular patterna) ametropic

- bilateral high hypermetropia- astigmatic

b) media opacity


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- cataract- corneal opacity- vitreous hemorrhage

Traditional Classification of Amblyopia1) strabismic2) refractive: anisometropic, astigmatic, high hyperopia, high myopia3) deprivation (occlusive or poor image)

Characteristics of Amblyopia1) abnormal contour interaction

- “crowding” phenomenon- spatial summation- lateral inhibition- receptive fields

2) central depression (larger in anisometropic than strabismic)3) RAPD in 10% (severe)4) abnormal VEP, pERG5) defect in accomodation6) no effect from neutral density filter7) eccentric fixation

Penalization Techniques1) Atropine- 0.5% atropine Qday to good eye- full correction in bad eye- works only in at least +3.00 hyperopes- the greater the hyperopia, the greater the amblyopia that can be treated with this- trial in office done with cyclogyl2) overplussing good eye with glasses3) patchinga) FTO: - good for significant amblyopia with no fusion- eg. constant strabismus- examine every x weeks (x = patient’s age)- continue until no improvement for 2-3 months (Polomeno)- risk of occlusion amblyopia until 5 years of ageb) PTO:- good for mild moderate amblyopia with some fusion- used for maintenence after FTO- eg.i) at home from school4) patch taped to glasses5) opaque contact lens

6) nail polish or tape to spectacle of good eye** Note: always try optical correction before penalization*** attempt trial of amblyopia until age 9- for non-patching treatments in straight eyes, you should check to make sure “bad” eye becomes the fixating eye (eg. vertical prism test)

Prescribing glasses in kids1) high hyperopes (> 5D?)2) asinometropic hyperopia > 1D3) bilateral astigmatism > 2.00 D4) unilateral astigmatism (or diff) > 1.5 D5) bilateral myopia > -10 D?6) anisometropic myopia > 6 D

Total Hyperopia:1) Manifesta) absolute (need to see 20/20)b) facultative (can add this and still see 20/20)2) Latent (uncovered by drops)

Classification of EsodeviationsA) congenital / infantile (< 6 months)1) essential esotropia (“congenital”)2) early onset accomodative3) Duane’s type I4) nystagmus blocking syndrome5) CN 6 palsy (or Moebius)B) acquired comitant1) high hyperopia2) high ACA3) mixed mechanism (ACA and hyperopia)4) decompensated accomodative5) cyclic ET6) divergence insufficiency/paresis ** often associated with brain pathology - scan!7) spasm of near reflex8) esophoria (common)C) acquired incomitant1) LR weak (CN 6 palsy, slipped muscle)3) MR restriction (#, TRO, postop)D) pseudostrabismus (epicanthus)

ExotropiaA) Intermittent XT1) basic type2) divergence excess (XT at far)true: still more XT at far with + 3.00 add at near


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pseudo: same one + 3.00 is added3) convergence insufficiency (XT at near) (CT head if complete convergence paralysis)B) Constant XT1) decompensated intermittent XT2) congenital XT3) sensory XT4) craniofacial anomaliesC) Incomitant XT1) Duane’s type II 2) CN 3 palsy

Treatment of accomodative ET1) cycloplegic refraction2) give glasses (full time!) (if not wearing glasses well atropine Qday to blur)3) see 1 week later to make sure wearing glasses4) see 8 weeks later any better?5) treat amblyopia6) rerefract 1-2 months after glasses given (see if any change)7) after amblyopia and glasses treatment, if ET> 10, then surgery

Treat high ACA1) bifocals2) if not wearing properly: atropine ointment with bifocals (for compliance)3) PI (0.125%) Qday to cause accomodation (must stop 6 weeks before surgery)

Surgery for accomodative ET not fully corrected by glasses1) treat with Fresnel prisms (BO) and then reexamine 2 weeks later2) If deviation is now greater, give more prisms (patient “eats up” prisms)3) continue this until no deviation with prisms4) surgically treat full deviation with prism adds

Non-Surgical Treatment of (X)T1) orthoptic treatment (fusional training, etc..)2) treat amblyopia if present (rare)3) minus lenses4) alternating occlusion ?? 5) BI prisms

Treatment of convergence insufficiency

1) orthoptic exercices to stimulate fusional amplitudes:i) practice reading through BO prismsii) pencil pushupsiii) red filter, light and prism bariv) stereograms2) BI prisms (tx)3) MR resection (last resort)

Treatment of DVD1) unil. SR recession (5-9mm)2) bilat. SR recession (7-10 mm)3) post. fixation (faden) sutures 12-15mm post. to insertion4) IO anteriorization (with IOOA)

Treatment of DVD + IOOAIO recession with anteriorization

Treatment of IOOA1) IO recession (8, 10, 14 mm)2) IO anteriorization2) IO myectomy

Treatment of SOOA1) silicone expander2) SO tenotomy

Treatment of A pattern (>10 PD between 25 degrees upgaze and 25 degrees down gaze)A) With SOOA1) SO tenotomy2) SO recession3) silicone expander

B) Minimal SOOAhorizontal recti displacement: (MR ; LR)i) ½ tendon width: 15 PDii) full tendon width: 30 PD

Treatment of V pattern (>15 PD between 25 degrees upgaze and 25 degrees down gaze)A) with IOOA1) IO recession (8, 10, or 14mm)2) IO myectomy3) recession with anteriorization4) IO extirpation5) vertical recti transposition (not used today)


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B) Minimal IOOAi) horizontal recti displacement: (MR , LR)i) ½ tendon width: 15 PDii) full tendon width: 30 PD

Treatment of SO palsy (Wright)I) IO recession (if worse on upgaze) - corrects up to 15 PD vertic. deviationII) SO tuck (for HT worse on down and in gaze or for bilateral SO palsy) III) contralateral IR recession (for HT worse on downgaze; 3 PD correction per mm recession)IV) ipsilateral SR recession (for HT worse on abduction or restricted downgaze on forced ductions) V) Harado Ito: anteriorization of SO; for problem with excyclotorion but little vertical deviation- NV: for 20-35 PD, do 2 muscles; for > 35 PD, do 3 muscles

Distinguishing DVD from IOOADVD:1) is same in abduction and adduction2) shows no hypotropia of opposite eye3) does not have V pattern

Brown’s causes:1) idiopathic2) JRA3) sinusitis4) trauma

Distinguishing Brown’s from IOUABrown’s:1) involved eye is abducted with upgaze (IOUA would be adducted)2) widened palpebral fissure on adduction3) positive rotational forced ductions, especilally with retropulsion)

Treatment of Brown’s1) SO tenotomy with IO recession2) SO spacer3) IO weakening procedure

Treatment of IO paresis1) SO tenotomy

Treatment of double elevator palsy (monocular elevation deficiency)1) If tight IR: recession of IR 6-8mm2) paretic elevation: Knapp procedure (MR and LR are transposed to edge of SR)

Treatment of CN 6 palsyA) if some LR function1) ipsil. LR rs + MR rc2) contral. MR rc + posterior fixation (optional)B) If no LR function: Jensen or Hummelsheim

Treatment of CN 3 palsy (eye is out and down)1) large LR rc and MR rs with supraplacement2) or for hypotropia: SO tenotomy or IR rc

Treatment of Duane’s1) ipsilateral MR recession2) ipsilateral MR rc and LR rc3) Faden suture to SR for leash phenomenon4) splitting LR for leash phenomenon

Treatment of congenital nystagmus1) Kestenbaum procedure: bilat rc/rs (see pseudonyms)

Tx of NBS1) bilateral MR rc with Faden sutures

Complications of Strab surgeryA) Intraop1) malignant hyperthermia or GA complic.2) perforated globe3) lost muscleB) Postop - Common1) pyogenic granuloma2) hematoma3) conjunctivitis4) adults - diplopia (20% without adjustables, 2% with adjustables - Connolly)C) Rare - serious1) lost muscle2) slipped muscle3) orbital cellulitis

Indications for re-op post ET surgery1) < 4 years: > 10 D (want binocularity)2) > 4 years: > 15 D (cosmesis)


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Treatment of post-op ET (surgery for XT)1) wait, it should get better2) BO prisms3) + lenses for hyperopes4) patching5) Reop as last resort

Indication for X(T) surgery1) increasing XT (size, frequency, duration) - indicates loss of fusion control and potential loss of binocularity- if parents notice frequency increasing or if MD’s examine demonstrates changesigns:1) increasing measurements2) remains XT after blink3) XT easily elicited looking in distance or quick cover 4) worsening performance on stereopsis tests ? (mine)Note: starts at distance and then develops at near

For strabismus onset after 10, patient may or may not be able to supress; to check:1) prescibe Fresnel prism for 1 month 2) if after 1 month patient develops either fusion or supression (ie no diplopia), then postop diplopia is unlikely

Indications for Strabismus surgery1) to gain fusion (kids)2) to treat diplopia (adults)3) cosmesis4) to treat asthenopia (eg. intermittent exo)5) head position

Surgical terms1) myotomy: cut the muscle in completely2) myectomy: cut out wedge of muscle to weaken 3) marginal myotomy: cut muscle incompletely (eg. to weaken rectus muscle that has been maximally recessed)4) extirpation: for IO, to remove it

Numbers:MR, SR, IR: 1mm gives 3 PDLR: 1 mm gives 2 PD

horizontal effect: bilat. IO recession: 0 PD in primary, 15-25 PD in upgazehorizontal effect: bilat SO tenotomy: 5-10 PD in primary, 30-40 PD in downgazebilat horiz. recti: 15 PD for ½ width displacement

Indications for Botox1) small to moderate angle ET or XT (< 40 PD)2) acute paralytic strabismus3) post-op residual strabismus4) cyclic ET5) diplopia when surgery contraindicated (eg. active TRO)

Three step Test for HT1) HT greater on right or left (pair up SR-SO; IR-IO)2) HT greater in ABD (IR-IO) or ADD (SR-SO)3) HT greater in ipsitilt or contratilt

Maximum surgery for usual ET and XT- can resect more than you can recess (slightly)MR: Rc: 6 mm; Rs: 6 mmLR: Rc: 7 mm; Rs: 9 mm

Exceptions1) XT > 40 PD with profound amblyopia2) cong. motor nystagmus: augmented

KestenbaumRc MR: 5Rs MR: 6Rc LR: 7Rs LR: 8

Minimum surgery (for 15 PD)MR: Rc: 3mm; Rs: 3 mmLR: Rc: 4mm; Rs: 4mm

Complications of Botox1) diplopia2) ptosis3) retrobulbar hemorrhage4) pupil dilation (ciliary ganglion)5) scleral perforation6) punctate keratitis?


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3) PLASTICSDDx of ulcerative blepharitisA) Bacteria: staph, moraxellaB) virus: HZVC) Fungus: candida D) Parasites: dermatophytes (Demodex?)E) Immune: lupus

DDx umbilicated lesionsA) Infectious: molluscum B) benign: keratoacanthoma, trichofolliculoma, sebaceous hyperplasiaC) malignant: BCC, squamos cell CA

DDX pigmented lesions of skin of lid1) nevus2) malignant melanoma3) BCC4) seborrheic keratosis 5) actinic keratosis6) SCC

BCC clinical types:1) Nodular2) Nodular/ ulcerative3) cystic4) morpheaform5) pigmented

DDx of ptosisA) Neurogenic1) Horner's2) IIIrd nerve palsy3) 3rd nerve misdirection4) Marcus-GunnB) Aponeurotic 1) involutional2) post-op3) blepharochalasis4) post-traumaC) Mechanical 1) scarring2) dermatochalasis3) tumors4) edema5) SR resection6) GPCD) MyogenicI) congenital

a) simpleb) blepharophimosis syndromeII) acquired a) myotonic dystrophy b) oculopharyngeal dystrophyc) CPEOd) post BotoxE) Neuromyopathic1) myastheniaF) Pseudoptosis1) lack of posterior support- enophthalmos- microphthalmos- phthisis2) contralateral lid retraction or exophthalmos3) hypotropia (pulls lid down)4) dermatochalasis (both true and pseudoptosis)5) eyelid tumor (chalazion, BCC)6) eyelid edema7) corneal disease

Ptosis with inflammationA) Neoplastic1) BCC2) SCC3) sebaceous CAB) Inflammatory - Lid1) chalazion2) contact dermatitis3) cellulitis4) TRO? 5) IOD?C) GPC related 1) CL2) suture3) prosthesis4) vernalD) chronic conjunctivitis1) bacterial2) chlamydial3) drops

DDx of Congenital PtosisA) Neuro1) jaw wink (Marcus Gunn)2) CN 33) Horner’s4) migraine5) CN 3 aberrant regeneration - CN 3


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B) Myogenic1) simple2) myastheniaC) Associated with ocular syndromes1) blepharophimosis2) double elevator palsyD) Aponeurotic1) congenital2) traumatic

Floppy eyelid associations1) obesity2) keratoconus3) eyelid rubbing4) eyelid mechanical pressure5) diabetes6) sleep apnea

Eyelid swelling/edemaA) Local causes1) aging (orbital fat herniation)2) allergy3) chalazion4) orbital disease5) dacryoadenitis (gland)B) Systemic causes (edema)1) heart disease2) renal disease3) hypothyroid4) urticaria (allergy)5) SVC synrome

Causes of canaliculitisA) Bacteria1) Actinomyces israelii2) NocardiaB) Fungi1) candida2) AspergillusC) Virus1) HSV2) HZVD) chlamydia- give Pen because besides actinomyces, rest are not bacteria and will resolve with hygene

Causes of acute dacryocystitis (sac)A) Gram + (more common)1) strep pneumo

2) staph aureus3) beta hemol. strep4) actinomyces?- all respond to CloxacillinB) Gram -1) pseudomonas2) H flu (kids)3) Proteus

Causes of chronic dacryocystitis (sac)A) Infectious1) strep pneumo2) H. flu3) TB4) syphilisB) Infiltrative1) sarcoid2) Sjogren’s3) lymphoid hyperplasia4) lymphoma5) SCC (blood in tears)6) adenocarcinoma (see blood)

Causes of acute dacryoadenitis (gland)A) Viral1) EBV2) mumps3) HZV4) influenzaB) Bacterial (secondary to conjunctivitis)1) staph2) gono 3) strepC) Inflammatory1) OID

DDx of chronic dacryoadenitis (gland)1) Sjogren’s2) sarcoid3) syphilis4) TB5) BRLH

DDx of lacrimal gland swelling1) non-epithelial (>50%)A) inflammatoryi) sarcoidii) OIDiii) Sjogren’s


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B) lymphoproliferativei) BRLHii) lymphoma2) epithelial (< 50%)a) benign mixed (pleomophic adenoma): 50%> 1 year, painlessb) rest (malignant): 50% i) adenoid cystic (50%) - “cylindroma”; (swiss cheese appearance); < 1 year, pain ii) malignant mixed iii) adenocarcinoma iv) mucoepidermoid v) squamous?

Lacrimal sac tumors1) squamous papilloma2) SCC3) adenocarcinoma

DDx of lymphatic dilations1) lymphangiectasia2) lymphangioma

Lymphoid rxns in orbit (same in conj.)1) BRLH2) Atypical lymphoid hyperplasia3) lymphoma4) lymphoplasmacytic proliferation5) lymphangioma

DDx of EOM thickeningA) Inflammatory1) TRO (muscle only)2) OID (muscle and tendon)B) Infiltrative1) lymphoma2) metastasis3) lacrimal gland tumor into muscle4) rhabdo5) amyloidC) Vascular1) C-C fistula2) A-V malformationD) Infectious1) trichinosisE) Other1) acromegaly? - like other tissues

DDx of EOM restriction

1) OID2) Graves'3) hemangiopericytoma4) mets (esp. breast and lung)

Ddx of intermittent proptosis1) sinus mucocele2) dermoid cyst3) lymphangioma (with URTI)4) orbital inflammatory disease5) TRO

Ddx of pulsating proptosis1) C-C fistula2) hypoplastic sphenoid; CSF into orbit3) meningocele (meninges herniate)4) encephalocele (brain herniates)5) fractures of orbit ?6) orbit surgery (transcranial orbitotomy)

Ddx of proptosis with crying or straining1) capillary hemangioma2) meningocele3) encephalocele4) orbital varices

DDx of congenital proptosis1) meningocele2) encephalocele3) teratoma of orbit4) capil. hemangioma (usually infancy, not cong.)5) sphenoid hypoplasia

Ddx of rapid increase in proptosisA) Neoplastic1) rhabdomyosarcoma2) mets (especially Ewing's)3) leukemia (unil. or bilat.); A.L.L. #14) orbital neuroblastoma (unil. or bil.)5) chloroma (leukemia)6) Burkitt’s lymphoma7) teratoma

B) Ruptures or bleeds 1) dermoid cyst rupture2) lymphangioma with hemorrhage3) ruptured hydatid cyst4) bleed from orbital varix5) coalescence of cysts in glioma(?)


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6) post-trauma

C) Inflammatory/ Infectious1) infectious cellulitis2) orbital inflammatory disease3) mucormycosis4) aspergillosis of orbit

Rapidly growing orbital tumor in child1) chloroma (leukemia)2) Burkitt’s lymphoma3) teratoma4) lymphangioma5) rhabdo6) neuroblastoma7) mets (especially Ewing's)

DDX enophthalmos1) post TRO2) post O.I.D.3) mets4) post-radiation5) post-blowout6) chronic sinusitis7) lying down with varix? (OKAP)

DDx of dry eye (decreased aqueous layer)A) Gland infiltration1) primary Sjogren's disease 2) secondary Sjogren’s (RA, SLE, PAN,…)3) leukemia4) lymphoma5) sarcoid6) amyloid

B) Decreased function1) post-menopausal women2) meds with antichol. activity: anti-depressants, anti-histamines, OCP?3) Riley-Day syndrome

C) Other1) post-blepharoplasty (damage to gland)

DDx of mucin deficiencyA) Inflammation Stevens Johnson, OCPB) Trauma: alkali burn, radiation damageC) Infection: trachomaD) Nutrition: Vit A deficiency

DDx of lipid layer deficiency1) rosacea blepharitis2) Acutane therapy

Langerhans granulomatoses (histiocyt. X)- proptosis, lytic skull lesions “EHL”1) +/- juvenile xanthogranuloma2) eosinophilic granuloma (local)“unifocal histiocytosis”3) Hand-Schuller-Christian (subacute, syst.)“ multifocal histiocytosis”- involves multiple sites4) Lettere-Siwe (acute, systemic); “diffuse soft tissue histiocytosis”- involves visceral organs

Causes of lid retraction: (Duane’s)1) TRO2) aberrant third nerve regeneration3) unilateral ptosis, with contralateral overaction of levator palpebrae4) Parinaud’s syndrome; bilat.5) hyperkalemic periodic paralysis6) chronic systemic corticosteroid therapy ?

Calcified lesions of the OrbitA) bone or c.t. origin1) osteoma2) osteosarcoma 3) ossifying fibroma4) chondrosarcoma 5) fibrous dysplasia (hyperostosis)B) Vascular1) hemangioma2) varicesC) Lacrimal gland1) adenoid cystic CA2) benign mixed (cart or bone)D) Globe- see pathE) Other1) meningioma (common)F) Chiasm tumor with calcification1) meningioma2) craniopharyngioma

Hyperostosis of orbit1) meningioma


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2) fibrous dysplasia

DDx of orbital bone destruction1) rhabdo2) adenoid cystic carcinoma3) metastatic carcinoma4) histiocytosis X5) dermoids6) multiple myeloma

Lytic lesions of skull1) histiocytosis X2) multiple myeloma3) mets

Causes of acquired canalicular obstruction1) trauma2) drugs: antivirals, miotics (IdU, PI)3) viral infections (HSV, vaccinia)4) autoimmune (Stevens Johnson, OCP)

Causes of NLD obstruction1) trauma2) sinus disease3) dacryocystitis4) involutional stenosis5) sarcoidosis6) Wegener’s7) lethal midline granuloma

Causes of dacryoliths1) Candida2) actinomyces3) epinephrine drops

Locations of orbit lesionsA) Superonasal1) meningocele/encephelocele2) fibrous histycytoma (most common site)3) rhabdomyosarcoma

B) Superotemporal1) dermolipoma (lipodermoid)2) dermoid/epidermoid cyst

C) Inferotemporal1) limbal dermoid of globe (assoc. with Goldenhar’s)

Locations of Choristomas of globe/orbit1) limbal dermoid of globe - solid tumor- inferotemporal most common- assoc. with Goldenhar’s- can cause astigmatism and amblyopia2) dermolipoma (lipodermoid)- solid tumor- same as dermoid but fat is greater component- most common superotemporal then superonasal- may extend into deep tissues- if removed, can cause strabismus and fat adherence syndrome- are best left alone3) dermoid/epidermoid cysts- cystic tumor which contain keratin- wall has skin appendages in dermoid type- superotemporal most common, then superonasal- rupture is very irritating (must excise whole if ruptures, irrigate ++)- usually attached to bone

Lateral Tissue prolapse1) dermolipoma (yellow)2) orbital fat prolapse (yellow)3) lacrimal gland prolapse (gray)4) lymphoma (salmon)5) dermoid cyst (white?)

DDx of multiple nodular lid lesions 1) sarcoid2) molluscum3) amyloid4) lipoid proteinosis5) granuloma annulare (SLE?)

DDx erythematous plaque of lid1) BCC2) squamous cell (in situ)3) discoid lupus4) actinic keratosis5) contact dermatitis


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C) TREATMENTSCosmetic treatment for microphthalmos1) prosthesis (scleral shell)2) evisceration3) enucleation4) Gundersen flap with scleral shell

Integrated Implants1) HA2) Medpor

Quasiintegrated implants1) Allen2) Universal

Spherical Implants1) PMMA

Other1) dermis fat graft - good for forshortened fornices- remove epithelium- from leg

Material for post lamellar grafting1) buccal mucosa2) ear cartilage - plenty- good structure- no epithelial surface (bad)- cysts form (bad)3) hard palate - plenty- no loss of function- epithelial- keratinized (bad)- irritating (bad)4) nasal septum- plenty- good structure-no epith (bad)- ophthalmo. unfamiliar with nose (bad)5) contralateral tarsus- good structure- epithelium- not a lot (bad)- shrinks (bad)- other eyelid retracts6) banked sclera

- plenty- resorbs (bad)

Sites for anterior lamellar grafting1) adjacent skin (flap)2) supraclavicular 3) preauricular skin 4) retroauricilar skin5) anterior forearm??

Materials for frontalis suspension1) autologous fascia lata2) donor fascia lata3) silicone rods4) supramyd (like Dacron)

Materials to replace orbital floor1) Silastic sheet2) Supramyd sheet3) Medpor sheet4) bone5) microplates

Lid position changes with strab surgery1) IR recess: lower lid retracts2) IR resection: lower lid advances3) SR rc: upper lid retracts4) SR rs: upper lid ptosis- IR / lower lid more sensitive

Treatment of cong. dacryocystoceleA) no infection1) conservative: ABC’s, massage2) if no change in 2 weeks or infection probingB) Gets infected1) systemic ABC’s2) surgical decompression: probing3) avoid I & D (fistula created)

Tx of canaliculitis1) unroofing canaliculus (cutting down over a probe)2) curet concretions3) send for culture and stain4) irrigate with antibiotics (Pen for actinomyces, nystatin for Candida) 5) topical antibiotics (Pen, Nystatin or Viroptic for HSV) for 1 week


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6) warm compresses

Treatment of dacryocystitis (adult)1) warm compresses 2) avoid irrigation until infection subsides3) oral antibiotics4) aspiration of lacrimal sac or I and D if localized absecc forms5) DCR eventually

Treatment of congenital NLD obstruction1) topical antibiotics2) massaging several times per day (removes bugs and may open duct)3) observe until 9 months4) probing (then irrigate with fluorescein)5) repeat probing with silicone intubation +/- infracture6) DCR at age 3 if not better

TRO muscle involvement: I>M>S>L

Decompession Order: M>I>L>S

Radiation doses for orbital disease1) TRO, OID: 1500-2000 rads (100 rads per dose)2) BRLH: 1500 rads3) lymphoma: 2000-40004) rhabdo: 4500-6000 over 6 weeks5) melanoma: 7000?

Radiation complications1) dry eye: 1000 rads2) cataract: 1000-2000 rads3) retinopathy: 5000 rads4) optic neuropathy: 5000 rads

Thyroid treatmentdecompress EOM surgery lids

Treatment of TRO acute congestive myopathy 1) steroids: 60 mg to start; for up to 3 weeks2) consider cyclosporin if not better

Treatment of TRO ON compression1) high dose steroids until no improvement for 1 week, then try something else

2) radiation (1500-2500 rads over 10 days) if responding to steroids but can’t be tapered (and continue steroids)3) orbital decompression if no improvement in 1 week4) VER’s to follow (or color plates)NB: if patient receives I131, needs steroids because TRO may worsen

Emergency Radiotherapy (within 12 hours)1) rhabdo2) leukemia of orbit

Encapsulated or pseudoencapulated lesions- don’t want to rupture these during surgery1) cavernous hemangioma2) hemangiopericytoma3) rhabdomyosarcoma4) dermoid5) Schwannoma (neurilemmoma)6) benign mixed tumor

Facial assymetry1) sphenoidal meningioma (temporal)2) fibrous dysplasia3) neurofibromatosis4) post radiation5) 4th nerve palsy6) Sturge Weber

Tx. of capillary hemangioma- treat for occlusion or astigmatism uncorrectable by glasses- laser ?1) steroid injection: short acting (Betamethasone 6 mg) and long acting triamcinolone (40 mg) every 2 months if necessaryor2) oral steroids (high dose) - systemic side effects3) consider systemic alpha interferon4) pulsed dye laser (controversial)

Orbital cancer that may be treated by complete excision of orbital lesion1) lymphoma2) metastatic carcinoid3) metastatic renal cell carcinoma


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Treatment of lid BCC1) if large full skin diagnostic biopsy2) if small and easily accesible excision3) if lesion near caruncl or punctum Moh’s (after diagnosis)4) no cryo?

Treatment of lid SCC1) examine lymph nodes2) diagnostic full skin biopsy3) excise (pentagonal) with frozen sections 4) remove 2mm of “normal” skin around margins5) cryo?

Treatment of sebaceous cell CA1) full thickness lid biopsy2) remove entire tumor + take multiple conj biopsies for Pagetoid spread3) 2 mm margins?

Treatment of lid melanoma (rare)1) diagnostic biopsy2) excise with frozen sections3) 2 mm margins

NB: every excision is full lid thickness

Late Causes of poor fitting prostheses1) poor fit of prosthesis2) tumor recurrence3) infection

Early causes of poor fitting prosthesis1) poor closure2) infection

Treatment of dehiscence of implant1) scleral patch and reclosure2) removal of implant witha) if conj. foreshrtened dermis fat graftb) if conj. volume OK new implant

Traetment of orbital floor #1) observe for 1 week while giving steroids (60-80 mg Qday)2) Repair ifi) enophthalmos > 2mmii) # > ½ floor

iii) muscle entrapment (diplopia within 30 degrees of upgaze or downgaze)

Complications of orbital floor #1) V2 anesthesia2) diplopia3) CSF leak4) vision loss

Complications of blowout # surgery1) diplopia2) visual loss or blindness3) infraorbital nerve anesthesia4) overcorrection of enophtalmos5) infection6) implant extrusion7) lymphedema8) damage to lacrimal pump9) lower eyelid retraction

Treatment of seborrheic keratosis1) shave biopsy2) or cryo

Treatment of Jaw wink (Codere)1) wink < 3mm or less: unil. ptosis surgery only2) wink > 3mm: bilateral disinsertion with frontalis suspension

Treatment of Congenital Ptosis (Codere)1) 4mm or less: levator resection2) > 4mm: frontalis suspension (bilateral probably better)

Resection in Congenital Ptosis (Duanes’)Ptosis Levator Function ResectionNo ptosis 15+ mm noneMild: 1-2 mm Good: 8 mm or more 10-13 mmMod.: 2-3 mm Fair: 5-7 mm 14-20 mmSevere: 4 mm Poor: 4 mm or less 20-26 mmSevere: >4 mm None front. sling(1:10, 2:15, 3:20, 4:25)

Indications for Frontalis Suspension (Kanski)1) severe ptosis2) Marcus Gunn jaw winking3) aberrant 3rd nerve regeneration4) blepharophimosis syndrome


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Indications for Fascinella Servat (Kanski)1) Horner’s2) mild ptosis

Treatment Mucor1) complete debridement until it bleeds2) ampho irrigation3) systemic ampho

Work up of Lacrimal Gland Mass1) Orbital CT2) CXR (TB and sarcsoid)3) CBC, ACE,FTABS, PPD, 4) lymphoma suspected (abdominal and head CT scan, bone marrow biopsy)5) lacrimal gland biopsy (lymphoma work up negative)

Indications for evisceration1) endophthalmitis

Advantages of Evisceration1) less disruption of orbit2) good motility3) technically simpler

Contraindications for evisceration1) sympathetic ophthalmia2) intraocular tumor3) blind painful eye of unknown etiology

Lymphangioma Treatment1) nothing2) excise3) CO2 laser4) cautery5) orbital decompression

Types of Exenteration1) subtotal: eye + orbital tissues2) Total 1+ periorbita +/- eyelids3) extended: 2+ bone

Causes of contracted sockets1) radiation2) implant extrusion3) alkali injury4) extensive laceration5) poor surgical technique

5) multiple operations7) removal of conformer or prosthesis for long period


cohen word files/neuro... · web view- anisometropia - unil. astigmatism. b) media opacity -...

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